Community Dental Health Coordinator (CDHC)

1. Community Dental Health Coordinator (CDHC)

2. Amid I. Ismail Chair, American Dental Association CDHC Curriculum Committee Jane Grover Director, Center for Family Health, Jackson, MI December 12, 2007 National Network for Oral Health Access (NNOHA) San Diego, CA

3. Outline • Definition of the CDHC? • Frameworks for increasing access and reducing oral health disparities • Current status of the CDHC project • Perspective of a FQHC dental director • Outcomes and evaluation

4. Definition of the CDHC Community health worker (CHWs) with DENTAL SKILLS

5. Definition of Community Health Workers • CHWs are community members who are • Trained to promote health, provide leadership, peer education, and resources to support community empowerment. • Trained to integrate information about health and the health care system into the community’s culture, language, and value system, thus reducing many of the barriers to health services.

6. CHWs Functions of the CDHC • Coordinate and navigate dental care • Advocate for individuals • Motivate and assist people to prevent dental and oral diseases • Educate community groups and individuals

7. CHWs Functions of the CDHC • Assist community members to enroll in Medicaid or other programs • Assist in reducing dental anxiety and fatalism • Provide social support and self-efficacy • Advocate for oral health • Advocate for the CHCs

8. Dental Skills of the CDHC • Screen for dental emergency and need for urgent care • Take of digital radiographs • Use an interactive online database to share information with the supervising dentist • Triage care based on disease and risk status

9. Dental Skills of the CDHC • Per the instructions of the supervising dentist, provide the following preventive procedures • Oral hygiene assessment and education • Gross scaling • Temporary GIC restorations • Topical fluorides • Sealants

10. Supervision of the CDHC • The CDHC will be a salaried employee of a community health center • They may also be hired by dental providers who serve low-income or rural communities • Geographic zones of practice will be determined state-by-state based on dental workforce shortages and disease levels

11. Frameworks The CDHC model is based on extensive experience with CHWs and expanded function dental auxiliaries

13. Effectiveness: CHWs • Improved outcomes for • prenatal care, • cancer screening, • child sick visits, • immunizations for children, • chronic illness care, • maternal health, • STD testing, • smoking cessation, and • mental health and outreach services.

14. Effectiveness of CHWs • Promoted weight loss and breastfeeding among African Americans • Reduced drug use • Increased condom use among homeless women, • Increased physical activity among African-American women with type II diabetes • Reduced missed appointments • Increased follow-up care.

15. What about capacity? • Triage patients based on their dental needs • Prevention in the community • Follow-up preventive and motivational interventions • Reduce missed appointments • Increase utilization • Increase revenues for the FQHC • Hire staff • Community health worker functions may become reimbursable in the near future

16. Net Balance To cover all cost in year one, the CDHC (HS graduate) must recruit around 550 patients or 2 patients per work day.

17. Trainees • DHs may be trained and certified as CDHCs • DAs may be trained and certified as CDHCs • High school graduates will enroll in a 12-month program • All trainees must work as interns at a FQHC or CHC for 6 months

18. States Sending a Letter of Interest

19. Site Selected For Demonstration Projects • Michigan • Site director Amid Ismail, University of Michigan • Urban site in FQHCs • Oklahoma • Site director Dunn Cumby, University of Oklahoma • Rural site which may include some Native American clinics • Native American Locations • Site directors Nancy Reifel and Donna Kotyk, UCLA • Using multiple sites (MT, SD, MN, and other states) • ADA House of Delegates allocated $2 Million to cover the cost of the demonstration projects with local funding sources.

20. Curriculum • First draft to be completed this December • 14 Modules • First 6 focus on CHW certification • 7 on dental skills (screening, radiographs, prevention of caries, periodontal disease, oral cancer) • 1 internship • Unique modules: motivational interviewing; detailed oral hygiene assessment using the Nexo Method; oral cancer screening; tobacco cessation

21. We will not drill our way out of the dental caries problem • We will not seal our way out of the dental caries problem • We will not scale our way out of the periodontal disease problem • We will not biopsy our way out of the oral cancer problem

22. Moving Forward Requires New Models that Promote Community-based and Individual-focused Changes in Social, Organizational, and Behavioral DeterminantsIntegrated Dental Care and Oral Health Promotion Model

23. FQHC dental directorDr. Jane Grover • The CDHC is at the door • What can they do? • Sites • Equipment • Supervision • Training of clinical and other FQHC staff • Benefits to my clinic • Costs and risks • Outcomes

24. Population: 140,267 (2000) Race: 88.7 Whites, 7.9 Blacks 0-19 years: 45,000 Medicaid: 14.0% (2000) Medicaid: 16.2% (2006) Dentists: 77 (2000) Dental Hygienists: 117 (2000) Preventive visits: 48.5% FQHC: 1 (3 sites) Dentists: 3.5 FTE DHs: 4 DA: 7 Patients/year: 8,500

25. Dental Skills CDHC • Screen for emergency dental needs using questionnaires and visual inspections • Immediate scheduling • We will see them when we find them • Screen for signs of caries, periodontal disease, and oral cancer • Take radiographs • Enter all data in the CDHC database • Triage patients based on urgency • Assess and improve oral hygiene practices • Map location of plaque in stagnation areas • Write oral hygiene goals card • Demonstrate how to remove plaque from stagnation areas

26. Dental Skills CDHC • Apply topical fluorides • Place sealants • Temporize cavities to remove foci of infection prior to application of fluorides and sealants • Risk-based preventive recall

27. CDHCCHW skills • What can they do? • Navigate dental care and referral • Dental anxiety • Oral health literacy • Nutritional literacy • Personal preventive plans • Pregnant women • Infant oral health • Education of caregivers (parents) • Oral cancer patients • Tobacco cessation • Coordination with medical providers

28. Coordination of Dental Care • Missed appointments • First contact in the community • Group education • Advocate on behalf of community members • Advocate on my behalf with community members • Follow-up with patients who need referral or follow-up care

29. Potential assignment sites • Schools • WIC/Head Start • Neighborhoods • Nursing homes • Waiting rooms of medical clinics • Emergency rooms in hospitals • Triage the waiting list for dental care

30. Equipment • Portable dental chair and light • Sealant unit (compressor, electric handpiece, air syringe, saliva ejector, high speed suction) • Nomad • PC with wireless card • Cell phone • Instruments • Mirror • PSR probe • Cotton pliers • Intra-oral light • Temporary restoration kits • Sundries • Autoclave (Statim) • Car (personal or FQHC owned) • Insurance

31. Remote Supervision

32. Training of staff who work with CDHC • Front desk staff who can schedule appropriately • Dental hygienists: Coordination between hygienists and the CDHCs to prioritize schedules based upon needs of patients • Dentists who will review screening records and questionnaires recorded by the CDHC to triage care and develop a management plan for the CDHC • Other FQHC providers who will benefit from working with the CDHCs (prenatal care, pre-term, diabetes, smokers) • Community outreach coordinators at the FQHC

33. Potential Benefits • Integrated dental care model • Risk-based preventive care at home or community • Increased productivity • Advocate for FQHC services in the community • Disseminate accurate information regarding locations, staff and hours of operation

34. Risks • Remote supervision • Quality of care • Capacity to meet increased demand for dental care • Turnover and cost of re-training • Uncompensated care

35. Outcomes • Access to dental care • Efficiency of operations (increase quantity and quality) • Reduction of severe disease • Prevention of early disease • Patient satisfaction and quality of life • Networks with community and professional organizations

36. To move forwardOral health Promotion, Prevention, within an Integrated Dental Care Model • Three demonstration projects in 2008-09 • Focus on • Integrated care • Oral health promotion • Disease prevention • Social and behavioral determinants